Provider Demographics
NPI:1639170194
Name:GARDIAL, PAUL RICHARD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:RICHARD
Last Name:GARDIAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:1408 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3534
Practice Address - Country:US
Practice Address - Phone:903-794-0515
Practice Address - Fax:903-793-8000
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3062207Q00000X
TXM7986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146876001Medicaid
TX8L13577OtherTEXAS BLUE CROSS BLUE SHIELD
AR04090020102OtherQUALCHOICE
AR5M095OtherARKANSAS BLUE CROSS
TXP00720347OtherRAIL ROAD MEDICARE
TX195221002Medicaid
TXP00720347OtherRAIL ROAD MEDICARE
AR04090020102OtherQUALCHOICE